Evaluation of surgical performance during laparoscopic incisional hernia repair: A multicenter study

Background: Laparoscopic incisional hernia repair (LIHR) is a common procedure requiring advanced laparoscopic skills. This study aimed to develop a procedure-specific tool to assess the performance of LIHR and to evaluate its reliability and validity. Methods: The Global Operative Assessment of Laparoscopic Skills-Incisional Hernia (GOALS-IH) is a 7-item global rating scale developed by experts to evaluate the steps of LIHR (placement of trocars, adhesiolysis, estimation of mesh size and shape, mesh orientation and positioning, mesh fixation, knowledge and autonomy in use of instruments, overall competence), each rated on a 5-point Likert scale. During LIHR, 13 attending surgeons and fellows experienced in minimally invasive surgery (MIS) and 19 novice surgeons (postgraduate years [PGYs], 3-5) were evaluated at four teaching hospitals by the attending surgeon, a trained observer, and self-assessment using GOALS-IH, and by a previously validated 5-item general laparoscopic rating scale (GOALS). Interrater reliability was assessed by intraclass correlation (ICC), and internal consistency of rating items was assessed by Cronbach's alpha. Known-groups construct validity was assessed by using the t-test and by correlating of the number of self-reported LIHR cases with the total score. Concurrent validity was assessed by correlating the GOALS-IH score with the GOALS general rating scale. Data are presented as mean and 95% confidence interval (CI). Results: Interrater reliability for the total GOALS-IH score was 0.79 (95% CI, 0.60-0.89) between observers and attending surgeons, 0.81 (95% CI, 0.58-0.92) between participants and attending surgeons, and 0.89 (95% CI, 0.76-0.96) between participants and observers. Internal consistency was high (Cronbach's alpha, 0.93). Experienced surgeons performed significantly better than novices as assessed by GOALS-IH (31; 95% CI, 29-33 vs. 21; 95% CI, 19-24; p < 0.01). Very good correlation was found between GOALS-IH and previous LIHR experience (r = 0.82; p < 0.01) and strong correlation between GOALS-IH and generic GOALS total scores (r = 0.90; p < 0.01). Conclusion: Surgical performance during clinical LIHR can be assessed reliably using GOALS-IH. Results can be used to provide formative feedback to the surgeon and to identify steps of the operation that would benefit from specific educational interventions.